Public health campaigns often try to scare people straight. But fear alone isn’t enough–people need to believe they have the power to turn their lives around.

The question of how to motivate behavior change at a public health level comes at a critical time in our nation’s history. At last count 36% of adult Americans have prediabetes, and many of the newly diagnosed will progress to full-blown type 2 diabetes in less than three years. What’s worse, almost 90% of people with prediabetes are unaware they have the condition, though it is clearly treatable. There is compelling evidence that if you are at risk, losing just 7% of your body weight through diet and exercise significantly reduces the chance you’ll develop diabetes.

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For decades, many health ad campaigns took the approach of scaring people straight (think back to the classic “this is your brain on drugs” television commercials). One of the most recent examples of this is an ad called The Real Bears, part of an obesity and diabetes prevention campaign sponsored by the Center for Science in the Public Interest. The ad spoofs the Coca-Cola bears drinking soda and becoming obese, losing teeth, experiencing erectile dysfunction, and even having a foot amputated. It has a catchy soundtrack by Jason Mraz and racked up over 2 million views. But does it work?

Sort of. Scientists who have studied scare tactics, often called “fear appeals,” know that they help convince people that they may be vulnerable to a certain threat (like a risk of developing type 2 diabetes). They also are pretty good at convincing people of the severity of a threat (as in, if I do end up with type 2 diabetes, it could kill me). But changed perceptions don’t always translate into better behavior. Why not?

It turns out that selling someone on a problem isn’t enough. You also need to sell them on the solution. Scientists have learned that the key is in coupling a fear appeal with a promise of “efficacy.” In other words, people need to believe they have the power to change, and that making a change will significantly alter the likelihood of developing the disease. A fear appeal needs four key ingredients to work:

Convince the viewer they may be vulnerable to a threat

And that the consequences of that threat are serious

But that they also have the power to change

And that doing so will make a difference

While this may sound like common sense, studies show that four out of five diabetes ads fail to include all of these “fear and efficacy” ingredients in their campaign.

Using this lens, let’s take a second look at The Real Bears ad. It only contains Ingredient #2–showing the viewer that diabetes has severe complications. But it does not make it clear that this applies directly to the viewer (after all, I’m not a bear). It also wastes an opportunity to convince the audience that they can easily give up soda drinking, and if they do, that the action will significantly reduce their diabetes risk.

But even if you manage to incorporate all four ingredients of effective fear appeals, there’s still more you can do to make them stick. According to Dr. Kim Witte and Dr. Mike Allen, you should also make sure to:

Directly address the barriers to change within your message (i.e. skills, costs, beliefs, emotions, etc.). For example, people must believe that they can actually stick to a new diet, and that the new diet will make a real difference in their health. So it is useful to clearly show how easy it is to make better food choices, and that it will not cost them a lot of time and money to do so.

Don’t focus too much on tailoring your fear appeal to your target demographic. Research shows that personality traits or demographic characteristics like gender do not appear to influence processing of fear appeals, except on rare occasions. For example, even if a particular health issue affects women more often than men, you shouldn’t target your fear appeal only to women.

Fear appeals tend to either result in people feeling a need to control the danger (by changing their attitudes, intentions, or behaviors) or control their fear (by using denial, defensive avoidance, and reactance). In other words, your message should prompt people to take action, not just try to avoid the emotional discomfort that you just caused them. Show some sketches or rough cuts to a real audience and measure their response. You’re looking to see whether your campaign had no effect (suggesting you should increase the perception of threat in order to motivate action) or if you unintentionally caused a strong fear control reaction (suggesting you need to increase their sense of efficacy to handle the threat).

Bottom line: fear appeals can–and do–work, but only in the hands of a skilled communicator. The key is to make sure that any fear you elicit is outweighed by a sense of efficacy that you inspire, or your message will backfire. And that’s the scariest possible outcome of all.

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About the author

Cameron Sepah is the medical director at Omada Health. His mission is to create tools that alleviate human suffering and promote well-being.